Penzel Construction Company, Inc.
Accident / Incident Investigation
Accident prevention is the key to eliminating possibility of injury to employees and property loss. Learning from past accidents is one of the key elements in accident prevention. This chapter addresses the procedures to be followed for all accidents resulting in employee injury or property damage. Accident investigations are NOT conducted to place blame, however to find the root cause(s) and prevent future accidents.
Conduct accident prevention and investigation training for supervisors.
Ensure all accidents and injuries are investigated.
Ensure immediate and long-term corrective actions are taken to prevent re-occurrence.
Maintain Accident Reports permanently on file.
Ensure proper entries are made on the OSHA 200 Log and First Report of Injury.
Provide all necessary medical care for injured workers.
Immediately report all accidents, injuries and near misses to their supervisor.
Assist as requested in all accident investigations.
Report all hazardous conditions and near misses.
In most cases, the area Supervisor conducts the investigation. Direct supervisors are familiar with employee's work environment & assigned tasks. The Supervisor is the person who must take the accident situation under control and immediately eliminate or control hazards to others.
Accidents are usually complex. An accident may have 10 or more events that can contribute to the cause. A detailed analysis of an accident will normally reveal three cause levels: basic, indirect, and direct. At the lowest level, an accident results only when a person or object receives an amount of energy or hazardous material that cannot be absorbed safely. This energy or hazardous material is the DIRECT CAUSE of the accident. The direct cause is usually the result of one or more unsafe acts or unsafe conditions, or both. Unsafe acts and conditions are the INDIRECT CAUSES or symptoms. In turn, indirect causes are usually traceable to poor management policies and decisions, or to personal or environmental factors. These are the BASIC CAUSES.
In spite of their complexity, most accidents are preventable by eliminating one or more causes. Accident investigations determine not only what happened, but also how and why. The information gained from these investigations can prevent recurrence of similar or perhaps more disastrous accidents. Accident investigators are interested in each event as well as in the sequence of events that led to an accident. The accident type is also important to the investigator. The recurrence of accidents of a particular type or those with common causes shows areas needing special accident prevention emphasis.
The actual procedures used in a particular investigation depend on the nature and results of the accident. The agency having jurisdiction over the location determines the administrative procedures. In general, responsible officials will appoint an individual to be in charge of the investigation. The investigator uses most of the following steps:
Define the scope of the investigation.
Select the investigators. Assign specific tasks to each (preferably in writing).
Present a preliminary briefing to the investigating team, including:
Visit the accident site to get updated information.
Prepare the necessary sketches and photographs. Label each carefully and keep accurate records.
Interview each victim and witness. Also interview those who were present before the accident and those who arrived at the site shortly after the accident. Keep accurate records of each interview. Use a tape recorder for severe accidents or incidents (only with written consent of the witness).
Analyze the data obtained in the above step. Repeat any of the prior steps, if needed.
Conduct a post-investigation briefing.
Prepare a summary report, including the recommended actions to prevent a recurrence. Distribute the report according to applicable instructions.
An investigation is not complete until all data is analyzed and a final report is completed. In practice, the investigative work, data analysis, and report preparation proceed simultaneously over much of the time spent on the investigation.
Gather evidence from as many relevant sources as possible during an investigation. Get information from witnesses and reports as well as by observation. Interview witnesses as soon as possible after an accident. Inspect the accident site before any changes occur. Take photographs and make sketches of the accident scene. Record all pertinent data on maps. Get copies of all reports that pertain to the case. Documents containing normal operating procedures, flow diagrams, maintenance charts, or reports of difficulties or abnormalities are particularly useful. Keep complete and accurate notes in a bound notebook. Record pre-accident conditions, the accident sequence, and post-accident conditions. In addition, document the location of victims, witnesses, machinery, energy sources, and hazardous materials.
In some investigations, a particular physical or chemical law, principle, or property may explain a sequence of events. Include laws in the notes taken during the investigation or in the later analysis of data. In addition, gather data during the investigation that may lend itself to analysis by these laws, principles, or properties. An appendix in the final report can include extended discussions.
In general, experienced personnel should conduct interviews. If possible, the team assigned to this task should include an individual with a legal background. In conducting interviews, the team should:
Not all people react in the same manner to a particular stimulus. For example, a witness within close proximity to the accident may have an entirely different story from one who saw it at a distance. Some witnesses may also change their stories after they have discussed it with others. The reason for the change may be additional clues.
A witness who has had a traumatic experience may not be able to recall the details of the accident. A witness who has a vested interest in the results of the investigation may offer biased testimony. Finally, eyesight, hearing, reaction time, and the general condition of each witness may affect his or her powers of observation. A witness may omit entire sequences because of a failure to observe them or because their importance was not realized.
Problem Solving Techniques
Accidents represent problems that must be solved through investigations. Several formal procedures solve problems of any degree of complexity. This section discusses two of the most common procedures: Change Analysis and Job Safety Analysis.
As its name implies, this technique emphasizes change. To solve a problem, an investigator must look for deviations from the norm. Consider all problems that can result from any unanticipated change. Make an analysis of the change to determine its causes. Use the following steps in this method:
Define the problem (What happened?).
Establish the norm (What should have happened?).
Identify, locate, and describe the change (What, where, when, to what extent).
Specify what was and what was not affected.
Identify the distinctive features of the change.
List the possible causes.
Select the most likely causes.
Job Safety Analysis
Job safety analysis (JSA) is part of many existing accident prevention programs. In general, JSA breaks a job into basic steps, and identifies the hazards associated with each step. The JSA also prescribes controls for each hazard. A JSA is a chart listing these steps, hazards, and controls. Review the JSA during the investigation if a JSA has been conducted for the job involved in an accident. Perform a JSA if one is not available. Perform a JSA as a part of the investigation to determine the events and conditions that led to the accident.
An accident investigation is not complete until a report is prepared and submitted to proper authorities. An accident report should be clear and concise. The purpose of the investigation is to prevent future accidents. The following outline has been found especially useful in developing the information to be included in the formal report:
Where and when the accident occurred.
Who and what were involved.
Operating personnel and other witnesses.
Operating personnel and other witnesses.
Account of the Accident (What happened?).
Sequence of events.
Extent of damage.
Agency or source (of energy or hazardous material).
Discussion (Analysis of the Accident - HOW; WHY).
Direct causes (energy sources; hazardous materials).
Indirect causes (unsafe acts and conditions).
Basic causes (management policies; personal or environmental factors).
Recommendations (to prevent a recurrence) for immediate and long-range action to remedy:
Direct causes (such as reduced quantities or protective equipment or structures).
Obvious accident causes are most probably symptoms of a "root cause" problem. Some examples of Unsafe Acts and Unsafe Conditions which may lead to accidents are:
Unauthorized operation of equipment .
Running - Horse Play Not following procedures By-passing safety devices.
Not using personal protective equipment (PPE).
Under influence of drugs or alcohol.
Environmental hazards Inadequate housekeeping Blocked walkways.
Improper or damaged PPE.
Inadequate machine guarding.
As a result of the finding is there a need to make changes to:
Work Stations Design.
Policies or procedures.
All accident reports will be forwarded to the Safety Director and maintained on file permanently. They shall receive timely review by upper management to ensure proper corrective actions have been taken.
First Report of Injury and OSHA 200 Log entries will be made within 48 hours of notification of injuries or illnesses by the Safety Director.